Today, Dr. Willey is the most successful stand-alone sleep practice in the United States.
It isn’t always pleasant or easy to speak of one’s missteps. A hallmark of dentistry is “getting it right” the first time and every time. Key to this commitment is a business model that sees 96-99% reimbursement of billed fees from dental insurance, and an EBITDA that reflects the profits they’ve earned .
What if the dentists weren’t getting paid? What if they did the work, paid the staff, paid the lab bill and did the treatment without paying themselves? How long could they hold on? More often than not this is the story we hear from dentists who start billing medical insurance. Here’s Dr. Rod Willey’s story:
- WILLEY WASN’T GETTING PAID . . .
Every weekend event, online course and extra training Dr. Rod Willey attended prepared him for being a dentist who exclusively treated sleep apnea and facial pain. When he was ready to make the final transition to a dedicated sleep practice, he brought in one of the ‘best’ trainers and consultants in the field, to his practice for a month of training, on three different occasions. Dr. Willey wanted to make certain everything was done exceptionally well by his hand and that his staff would not be left to wing it. Training was key and he paid the price for every minute of it.
The president of The Compliance Team seeks to demystify the accreditation process for sleep labs.
After meticulously building a solid reputation in the world of DME accreditation, Sandra Canally is determined to bring her simplified approach to sleep labs. As president of The Compliance Team Inc, based in Spring House, Pa, Canally has long worked on the premise that excellence in health care delivery is best achieved by dramatically simplifying quality standards.
In Fall 2006, The Compliance Team (TCT) got a chance to implement this philosophy in a big way when the Centers for Medicare and Medicaid Services (CMS) formally granted the company deemed status to accredit providers of all types of DME, prosthetics, orthotics, and supplies (DMEPOS). Beyond the mandates that often accompany accreditation, Canally believes the entire process ultimately boosts patient care and improves business practices.
While TCT continues to actively accredit home care providers, these days company officials are also targeting sleep centers that may be looking for an alternative to the American Academy of Sleep Medicine (AASM). “I created the sleep center program quite a few years ago,” says Canally, who launched the Exemplary Provider™ accreditation programs more than a decade ago. “I created it because DMEs were expanding and adding CPAP—and doing a lot of business with sleep labs.”
With “deemed” status for DME now long established, Canally can accredit sleep labs that wish to “self dispense” CPAP units. “We can package the sleep lab and CPAP sales together and you are fully approved to bill Medicare,” says Canally. “The major national sleep organization [AASM] is not able to do that because they are not CMS approved for DMEPOS.”
Beyond the Medicare scenario, TCT can offer accreditation for sleep labs that encompasses all aspects of the lab’s operations. “A big misconception is that the major national sleep organization is the only player, and the same thing can be said of hospitals when it comes to the Joint Commission,” says Canally. “We provide an alternative that is not all about the minutia and jumping through hoops. We believe in simplification. We have led the movement within DME and other markets, and we are introducing these accreditation concepts for sleep centers. Simplification leads to clarity, and clarity allows the provider to focus on what matters most—safety, honesty, and caring.”
These three principles are all part of what TCT officials call the “Exemplary Provider” brand. “The word ‘exemplary’ means you are setting yourself apart from other providers that are just doing the minimum,” says Canally. “To accredit, you need to score 90% or better. So already we are setting the bar higher as our minimum standard.”
These days, TCT is opting to renew accreditation on a 3-year term, as opposed to the old 1-year process. During the 3-year span, providers still send in required items such as updated quality initiative plans, licensure documents, and proof of annual training.
In-person visits can be expected at least once during the 3 years, perhaps twice depending on the product lines. Second visits are focused only on patient care. “Since patients come in to a sleep lab in the evening, the sleep labs that we have accredited thus far have required night visits,” says Canally. “For one company that had three locations, we went in during the evening and stayed through the night and into the morning to see the whole process.”
With other sleep labs, TCT members have instead gone in extremely early in the morning. With this method, they could still see patients waking up and were able to ask questions about the night before, as well as take a peek at the sleep study. “We are not bound by Medicare to do unannounced visits on sleep labs,” explains Canally. “Unlike us, the AASM puts their complete focus on the medical director and the sleep study itself—all the technical aspects.
“My belief, and this is at the foundation of our program, is that the full evaluation should encompass operational excellence,” adds Canally. “Operational excellence leads to clinical excellence. You are not going to have the very best sleep study if you are not doing things right operationally—and that is the big difference between us and the AASM. We are looking at the whole picture of the organization, and they are looking at a small picture.”
If providers, including sleep labs, do not want to get accredited, or don’t need to do it for Medicare, there are other payors out there too. “A lot of the private pay organizations in managed care require accreditation to get on their network,” says Canally, who still maintains her active RN license. “A lot of the state Medicaid organizations are going toward accreditation. It’s just good business practice.”
Accreditation usually takes between 3 and 4 months, and most of the time it is a relatively pain-free process. Canally attributes the lack of pain to simplified standards that are written in plain language. “Providers are more compliant because there are no surprises,” says Canally. “We want their focus to be on improving operations and better serving patients.”
Just shy of a year on the market, the SleepView from CleveMed has managed to carve a growing niche in the highly competitive world of home sleep monitoring. Sarah Weimer, director of Sleep Products at the Cleveland-based manufacturer, touts the device as the smallest and lightest home sleep monitor within the AASM-recommended Type 3 channel-set guidelines.
At a weight of approximately 2 ounces, the equipment is ergonomically designed for patients to perform a self test at home, while also working hand in hand with CleveMed’s eCrystal PSG Web Portal.
The eCrystal PSG web service is offered at three different service tiers to meet the needs of various customers. We offer a full service with use of our eCrystal PSG web portal, scoring and interpretation for customer who are not affiliated with a sleep center. Our mid tier service includes use of eCrystal PSG and scoring. With this service a registered sleep technologist verifies the scoring and creates a draft of the report to be completed by a sleep physician. We also offer web portal use only. This service is used by centers that have personal for scoring and interpretation but wish to take advantage of easy web access to the data. Sleep studies can be uploaded from the point of patient care.
Easy for Patients
While Medicare approved home sleep testing last year, reimbursement still stands at just over $200. At that rate, Weimer points out that it is not cost effective for sleep labs, especially if sleep professionals must be involved with the setup every step of the way. “With that in mind, the goal with the SleepView was to make a device that fulfilled the channel set asked for by AASM, with the types of sensors that they like to see as well,” says Weimer. “At the same time, we wanted it to be very easy for patients to do a self hook up with minimal instruction.”
Clevemed was uniquely suited to do an incredibly small Type III device due to the company’s long history of producing wireless electrophysiology monitors. Working within the diminutive design parameters, engineers sought to avoid the more complex harness systems used by competitors. “We wanted it to be small and light enough that it could be supported by a traditional respiratory effort belt,” reveals Weimer. “It is easier for patients to hook themselves up. They don’t have to worry about extra mounting straps or the discomfort of having the device worn elsewhere on the body.”
Not surprisingly, patients appreciate how easy it is to put on the SleepView. For patients who think it may be too easy and question the procedure, engineers went an additional step with LED light indicators on the front that let patients know if they have hooked themselves up properly. “If they turn the device on, but they don’t have sensors on, there is a little light on the front of the device by each channel name that will light up red to let them know that they are not hooked up properly,” explains Weimer. “As they get each channel hooked up correctly, those lights will turn green to indicate that it is collecting a good signal. When the patient first turns the device on, those lights will stay on for 90 seconds, and then anytime during the night the patient can hit the ‘on’ button again to get another 30 seconds of feedback about whether the device is collecting good signals or not.”
Feedback on usability and success rates tabulated from sponsored tests have consistently shown that patients come back with valid data. “Other customers have been using our other product, the Sleep Scout, which is a little bit more traditional and a little bit more complicated for the patient to put on,” says Weimer. “It [the Scout] does not have the feedback, and we would have an increased number of unsuccessful studies with that product compared to this product. The immediate patient feedback on the SleepView lets patients know that they may not have a sensor in place properly, and they can fix it right away.”
Expanding the Market
Weimer agrees that the SleepView, and home testing in general, will likely expand the market for sleep labs by increasing access and awareness to potential patients. The undiagnosed masses will get into the treatment cycle, benefitting all parties throughout the continuum of care.
As more clinicians learn about the importance of sleep, referrals will also increase the flow of patients. “Patients are typically seeing their dentists or primary care physicians, and if those health care professionals are asking the right questions about sleep, it is just going to increase the number of people who are aware and getting tested,” says Weimer.
SleepView at a Glance
Hardware Dimensions: 3” × 2.6” × 0.7” (7.6 cm × 6.6 cm × 1.8 cm) Weight: 2 oz (57 g) (approx.) with batteries Power: 1 AAA battery Memory: 1G internal memory
7 Dedicated Channels
- Heart Rate
- Pulse Oximetry
- Airflow (pressure based)
- Airflow (thermistor)
- Snore (derived from airflow)
- Respiratory Effort Belt (RIP)
- Body Position
SleepView works with the eCrystal PSG Web Portal, allowing treating physicians to initiate home sleep tests directly from their practices. Data from the SleepView is uploaded through the web portal to a network of professional technologists and sleep physicians for timely scoring and study interpretation.
Later reports with recommended treatment or follow-up are retrieved by the treating physician. This patient monitoring system allows physicians to provide a continuum of care.
For more information, visit http://www.clevemed.com
The move would postpone a 25% reduction in physician fees for another year.
AP: The Senate approved a measure Wednesday to avoid a steep cut in Medicare pay for doctors by shifting some money from President Barack Obama’s health care overhaul law.
The deal by Senate leaders of both parties was approved by a voice vote and appeared headed for passage by the House, which would send the measure to Obama for his signature. The president had urged lawmakers to move quickly.
“This agreement is an important step forward to stabilize Medicare,” Obama said in a statement.
When Democrats passed the health care law, they used Medicare cuts to pay much of the cost of providing insurance to millions who lack coverage. Now, lawmakers are reversing the money flow to stave off a scheduled 25 percent cut to doctors on Jan. 1, tapping financing for the health care overhaul to keep Medicare from breaking down.
The $19 billion to pay doctors at current rates for another year will come mostly from tightening the rules on tax credits in the health care law to prevent waste. The credits will make premiums more affordable for millions.
It might seem like the proverbial robbing Peter to pay Paul, with a game of budget tag thrown in.
As bewildering as it sounds, the maneuver shows how federal health care funding is increasingly connected — even among programs serving different constituencies. Just last week, Obama’s deficit commission called for a single government health care budget, a step to getting costs under control.
“Health care spending is a significant part of the federal budget,” said Alex Vachon, a health policy consultant who has served as a Senate GOP aide. “So if they are going to go looking for health care money, they’re going to want to get it from another health care program.”
The move also indicates there could be billions more to be squeezed from such tweaks to the health care law.
Under the overhaul, millions of workers and their families will be eligible for tax credits to help pay insurance premiums. Those subsidies can add up to thousands of dollars per household, available up front each year starting in 2014. The aid is based on income, and people who make less will receive more.
But what if somebody gets a raise, a bonus or a higher paying job later in the year — and they keep quiet about it?
If the government finds out, the law as originally passed said individuals would have to pay back up to $250, and families up to $400.
The latest deal would replace that formula with a sliding scale. That means households with higher incomes would have to pay back a bigger chunk of their tax credit, subject to a limit.
The change shouldn’t significantly affect how many people seek tax credits to buy a policy through new health insurance markets, a congressional aide familiar with the details said. Starting in 2014, most Americans will be required to carry coverage and insurance companies will no longer be able to turn away those in poor health, or charge them more.
For Medicare, the agreement by Senate Majority Leader Harry Reid of Nevada, Republican leader Mitch McConnell of Kentucky and other senior senators is likely to only buy time.
The doctor cuts are the result of a 1990s budget-balancing law that tried, but failed, to keep Medicare spending in line through automatic reductions. Congress repeatedly stepped in to waive the cuts. Lately, lawmakers have had to act every few months.
Congress was under tremendous pressure this time, with medical groups estimating that as many as two-thirds of doctors would stop taking new Medicare patients. Health care for military service members, their families and retirees was also in jeopardy, since Tricare payments are tied to Medicare’s.
Congress will use the 12-month reprieve to try to come up with a new way of paying doctors that rewards quality care instead of sheer numbers of tests and procedures.
“For too long, we have confronted this recurring problem with temporary fixes and stopgap measures,” Obama said. “It’s time for a permanent solution that seniors and their doctors can depend on, and I look forward to working with Congress to address this matter once and for all in the coming year.”
DMEPOS Competitive Bidding Contract Supplier List in CPAP Devices, Respiratory Assist Devices, and Related Supplies and Accessories.
CONTRACT SUPPLIERS SELECTED UNDER NEW MEDICARE PROGRAM
1,217 contracts awarded to suppliers of medical equipment and supplies selected through competitive bidding in nine areas; program saves money for beneficiaries while preserving access to high quality items.
The Centers for Medicare & Medicaid Services (CMS) today released the list of the 356 suppliers that have contracts with Medicare to provide certain medical equipment and supplies to beneficiaries in nine communities across the U.S. at competitive bid rates. This new program, authorized by Congress, is expected to save Medicare and its beneficiaries nearly $28 billion over 10 years.
“We are pleased that Medicare beneficiaries living in the nine first round communities will be saving money and will continue to receive high quality service and supplies from the suppliers who were awarded contracts in Medicare’s competitive bidding program,” said CMS Administrator Donald Berwick, M.D. “Each of these contract suppliers has met our stringent standards, so beneficiaries can be assured they will receive their equipment and supplies from legitimate and quality suppliers at prices that are more in line with the current market.”
The new competitive bidding program goes into effect on January 1, 2011, for beneficiaries in the Charlotte, Cincinnati, Cleveland, Dallas, Kansas City, Miami, Orlando, Pittsburgh and Riverside areas (more detail on locations below). This program used bids from suppliers that represented the local, competitive marketplace to lower the costs for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) for Medicare beneficiaries to obtain medical items and supplies. Because beneficiaries pay 20 percent coinsurance on the payment amount for DMEPOS, they will directly benefit from the lower prices. Based on bids submitted by these suppliers, beneficiaries and Medicare will see prices, on average, 32 percent lower than Medicare currently pays for the same items.
CMS awarded 1,217 DMEPOS competitive bidding program contracts with 356 suppliers. The contract suppliers have 662 locations to serve Medicare beneficiaries in these competitive bidding areas. All contract suppliers were required to comply with Medicare enrollment rules, be licensed and accredited, and meet financial standards. 76 percent of contracts were awarded to suppliers already furnishing contract items in the local area.
Additional contract suppliers have furnished other items in the local area or furnished contract items in other areas: fully 97 percent of contracts were awarded to suppliers already established in the competitive bidding area, the product category, or both. Small suppliers, those with gross revenues of $3.5 million or less as defined for the DMEPOS competitive bidding program, make up about 51 percent of the contract suppliers. CMS received 6,215 bids from 1,011 suppliers during a 60-day bidding period last year.
To take advantage of the lower prices for the items that were part of the competitive bidding program, Medicare beneficiaries living in one of the competitive bidding areas who have ongoing need for a DMEPOS supplier may need to choose a new supplier if their current supplier is not a contract supplier and they wish to have Medicare continue to cover their equipment and supplies. A beneficiary may, in some situations, also be able to continue to receive certain items from a grandfathered supplier. Grandfathered suppliers are non-contract suppliers that provide certain rented equipment under the terms of the program.
CMS will now launch a comprehensive public education effort to ensure that beneficiaries, healthcare professionals, and others have the information they need to understand the new program. This effort will include mailings to beneficiaries, a full range of Internet-based and printed program information, and educational teleconferences. In addition, the 1-800-MEDICARE customer service representatives and case workers will be ready to assist beneficiaries.
CMS will also be monitoring program implementation closely. Monitoring methods will include:
- beneficiary surveys,
- active claims analysis,
- local surveillance and resolution of any program issues by CMS Regional Offices and local ombudsmen, and
- contract supplier reporting and tracking and analysis of complaints and inquiries.
In addition, the Competitive Acquisition Ombudsman will respond to complaints and inquiries from suppliers and beneficiaries about the application of the program and issue an annual Report to Congress.
“Medicare contract suppliers signed contracts that included terms such as protections to ensure that they will furnish beneficiaries with necessary equipment and quality customer service, starting on January 1, 2011,” said Berwick. “Medicare will hold contract suppliers to their obligations and will take action to address any contract performance problems.”
Consumers, physicians and other providers can find a list of Medicare contract suppliers in the nine initial areas of the program by visiting www.medicare.gov (under “Resource Locator” select “Medical Equipment and Supplies”) or by calling 1-800-MEDICARE (TTY users should call 1-877-486-2048). People can also visit the local offices of the various partner groups for help in finding a Medicare contract supplier, such as their State Health Insurance and Assistance Program, Area Office on Aging and a number of community organizations that can provide information on the program.
The Medicare DMEPOS Competitive Bidding Program was established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), and the program was briefly implemented in 2008 in 10 areas before it was temporarily delayed. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), enacted on July 15, 2008, terminated the supplier contracts in effect at the time, temporarily delayed the program and made certain limited changes to the program. MIPPA also required CMS to conduct the competition again for Round One in 2009, and delayed competition for Round Two in 70 additional metropolitan statistical areas (MSAs) until 2011 and in additional areas of the country until after 2011. The Affordable Care Act of 2010 expands the number of Round Two MSAs from 70 to 91 areas.
With the exception of Puerto Rico, the Round One Rebid was required to be in the same areas in which the program was briefly implemented in 2008. These areas are:
- Charlotte — Gastonia — Concord (North Carolina and South Carolina)
- Cincinnati — Middletown (Ohio, Kentucky and Indiana)
- Cleveland — Elyria — Mentor (Ohio)
- Dallas — Fort Worth — Arlington (Texas)
- Kansas City (Missouri and Kansas)
- Miami — Fort Lauderdale — Pompano Beach (Florida)
- Orlando — Kissimmee (Florida)
- Pittsburgh (Pennsylvania)
- Riverside — San Bernardino — Ontario (California)
The Round One Rebid was required to include the same items as the 2008 program except that negative pressure wound therapy items and Group 3 complex rehabilitative power wheelchairs are excluded. These items include:
- Oxygen, Oxygen Equipment, and Supplies
- Standard Power Wheelchairs, Scooters, and Related Accessories
- Complex Rehabilitative Power Wheelchairs and Related Accessories (Group 2 only)
- Mail-Order Diabetic Supplies
- Enteral Nutrients, Equipment and Supplies
- Continuous Positive Airway Pressure (CPAP) Devices, Respiratory Assist Devices (RADs), and Related Supplies and Accessories
- Hospital Beds and Related Accessories
- Walkers and Related Accessories
- Support Surfaces (Group 2 mattresses and overlays in Miami-Ft. Lauderdale-Pompano Beach, FL only)
For additional information about the Medicare DMEPOS Competitive Bidding Program, please visit:www.cms.hhs.gov/DMEPOSCompetitiveBid/
As the marketing push for ResMed’s S9™ Series reverberated around the 24th APSS (American Professional Sleep Societies) meeting in San Antonio, the San Diego-based company’s VPAP™ Tx Lab System quietly began to build its own momentum. Billed as an “all-in-one” titration solution for sleep labs, the unit contains all ResMed therapies, including adaptive servo-ventilation (Adapt SV), which treats central sleep apnea, mixed apneas, and periodic breathing.
According to Elizabeth Little, VPAP Tx Product Manager at Resmed, most people were surprised to hear the system includes all ResMed’s therapies. They expected Adapt SV to remain separate, and were pleasantly surprised to see it in the mix. “Our goal with the VPAP Tx was to build a product that would be easy for sleep techs to use and extremely comfortable for patients,” said Little. “We studied the work flow of technicians, and minimized the number of steps they need to take. Swapping out the bedside device for one therapy mode vs another was cumbersome, and the way to eliminate that was to put all of our superior therapies in one system. We put lab technicians’ needs at the forefront when developing this product.”
Throughout the conference, Little kept up a continual dialogue with sleep technicians and lab managers about the finer points of the new system. Little reports that many technicians were very impressed with the highly intuitive software. Among the most popular features were the therapy default settings, which are customizable and automatically reset to baseline pressure upon startup, eliminating a step for the tech, and preventing them from accidentally startling the patient with a blast of pressure. Additionally, she pointed out the “Detailed Settings Report,” which provides a complete record of all changes made to therapy during the night, giving them visibility to the performed by the techs, and allowing them to identify areas where training is needed.
A bilevel function delivers two treatment pressures—one for inspiration and one for expiration—and provides control over a variety of bilevel therapy modes. This integrated approach is a first for ResMed, and Drew Terry, senior director, product management, sleep SBU, says that a few months into the launch has seen many labs convert to the new unit with success. “The techs like the easy layout,” enthuses Terry. “They can go from CPAP mode to bi-level mode during the testing process, and it does it in an intelligent way—giving full control while also making recommendations. New technicians won’t spend a lot of time figuring out how to set things up. It’s automatic but it also allows you to make any necessary adjustments.”
After sleep lab technicians use the VPAP for titration, patients may ultimately go home with an S9 CPAP. Those that opt for this route will get many of the same features and technologies that served them during testing. “They can sleep with the Easy-Breathe Waveform, which synchronizes pressure with natural breathing patterns,” says Terry. “They will get the same ultra-quiet therapy in the home that they experienced in the lab. By maintaining consistency between the lab and home therapy, you are maximizing the patient’s chance for success.”
On the home care side of the sleep business, HME providers were left reeling in July when CMS announced new winning bid prices in the Medicare competitive bidding program. Unless legislative remedies derail the program, home care providers in 9 of the nations metropolitan areas will take a 32% cut in their Medicare allowable for CPAP units in 2011.
Currently, sleep labs must refer all Medicare CPAP patients to an HME to fulfill the prescription. “Some reports have shown that more people are considering dispensing, and that is something sleep lab owners may consider when looking at all the forces on their business,” says Terry. “Getting into the home care side of the business is another opportunity, and I think a lot of people are considering it. It’s a relatively small percentage of labs that are doing it right now—probably less than 20%. It’s a different business than running a lab.”
It is a competitive business environment for labs and many labs are looking for additional ways to serve their patients and grow their business. “They are considering how they might include home testing in their service offerings,” says Terry. “Although the revenue for a home test is less than what the in-lab tests are, labs are looking at that as a way to bring in additional patients who maybe would not have come into the lab anyway.”
S9 Still in Spotlight
Despite reimbursement uncertainties, trade show season has been kind to San Diego-based ResMed as the company continues to market its S9™ flow generators. The makers of the Swift and Mirage CPAP masks are spreading news of the S9‘s treatment technology in an attempt to create maximum value, an attribute that company officials say is even more important during uncertain times. “Our goal in the development of the S9 was to create a system that offers more than any other device on the market–more comfort, more control and more style–so users can feel confident about incorporating it into their lifestyle, and health care providers can be confident that their patients are receiving the highest quality of sleep apnea treatment,” said Terry.
Terry says the S9 represents a new approach to patient compliance, essentially making it easier for users to accept CPAP on their own terms. “It puts them in control of the details that make the difference in their personal comfort, like EPR™ level and humidification settings,” adds Terry. “It has intuitive menus and dials to make it easy to adjust. It reduces noise to a virtual whisper, so it won’t disrupt a sleeping partner. And it comes in a stylish design that looks like something they want to have at their bedside.”
With the S9 Series, ResMed has introduced a number of improvements, including Enhanced AutoSet™ and Easy-Breathe algorithms—and an improved Easy-Breathe motor for low noise levels. The S9 provides detailed data reporting for clinicians, and a complete S9-compatible wireless compliance management package to streamline business efficiencies. A humidification system with Climate Control intelligently adapts to the user’s real-time environmental conditions to provide optimum performance and humidification delivery. An innovative SlimLine™ tube eliminates tube drag.
Ultimately, the S9 is a large part of the overall push toward greater innovation in what will surely be a huge decade for sleep medicine. Companies big and small are all angling to serve the growing market, and Terry acknowledges that competition is fierce.
Elizabeth Little is Product Manager Sleep, based with ResMed in San Diego, CA.
For more information, visit www.resmed.com